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This article will support the view that white-coat hypertension (WCH), that is, the association of an elevated office with a normal ambulatory or home blood pressure (BP),1 is not an innocent condition but a condition associated with an increased cardiovascular risk. This will be based on the evidence that compared with normotensive controls, subjects with WCH (1) have an increased prevalence of metabolic risk factors and asymptomatic organ damage; (2) more frequently progress to high cardiovascular risk states such as sustained hypertension, diabetes mellitus, and left ventricular hypertrophy; and (3) exhibit, over the mid and long term, a greater risk of cardiovascular morbid and fatal events. It will also be mentioned, however, that important clinical and mechanistic aspects of WCH remain incompletely clarified: the contribution of office versus out-of-office BP to the increased risk; the biomarkers that may allow to distinguish, within the WCH population, subjects at greater versus those at normal risk; and the effect of antihypertensive drug administration on patients’ prognosis. Clarification of these aspects represents a priority for medical research because WCH is common in all hypertension grades, its prevalence accounting for more than one third of the hypertensive population when the office BP elevation is mild.2

Cross-Sectional Evidence

Metabolic Risk Factors

Evidence is available that subjects with WCH have an unfavorable metabolic profile. This was already observed many years ago3 and has since been confirmed by virtually all studies that have addressed this matter. A pertinent example is the PAMELA study (Pressioni Arteriose Monitorizzate e Loro Associazioni) on a population living in the north-east outskirt of Milan, in which measurements included a large number of metabolic variables. As shown in Figure 1, compared with normotensive controls, individuals with WCH (identified by an office BP ≥140/90 mm Hg and a 24-hour or home BP, respectively, <125/80 and 135/85 mm Hg) …